Does attachment insecurity predict auditory hallucinations?

As a final test of the specificity of the relationship between attachment insecurity and paranoia, a multilevel linear regression model was estimated with 1 2 3 4 5 6 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 A tt ach m en t Insec u ri ty Days clinical control

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auditory hallucinations as the dependent variable, and attachment insecurity and auditory hallucinations (both measured at the previous assessment point) as the independent variables. The results revealed that the presence of auditory

hallucinations was predicted by a preceding elevated level of attachment insecurity (OR = 1.285, SE = .145, p < .05, 95% CI [1.030 - 1.603]). This effect was no longer significant after controlling for concurrent paranoia (OR = 1.210, SE = .138, p > .05, 95% CI [.967 – 1.513]).

3.6 Discussion

In this study we sought to measure momentary attachment using experience sampling, and to examine the relationship between these representations and

paranoid thoughts in the context of daily life of individuals with psychosis. The main finding was that elevated attachment insecurity was followed by increases in

paranoid thinking, even when self-esteem was controlled for, and that this effect was specific to paranoia but not to hallucinations.

The strong negative association between mean momentary attachment insecurity measured by ESM and the secure attachment ratings on the RQ suggest that the ESM assessments had some validity. The validity of the ESM ratings was also supported by the fact that those participants who self-described as insecure on the prototypical RQ styles also showed less secure attachment on the ESM ratings than the self-described securely attached participants. However, there were at best modest associations between the momentary ESM attachment measures and the preoccupied and dismissive attachment ratings on the RQ. Hence, the ESM measure appears to be a relatively non-specific indicator of attachment insecurity.

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As noted in the introduction, attachment theorists from Bowlby onwards have suggested that attachment behaviours and internal working models may fluctuate over even short periods, as internal working models become activated by context. It has been proposed that these fluctuations can be driven by tentatively held beliefs about the self and others (Davila et al., 1997). Thus, those who fluctuate may be highly uncertain about their attachment-related thoughts and feelings, for example about the extent to which they can depend and trust others and the extent to which they can become emotionally close to others. In contrast, those who do not fluctuate are considered more likely to hold higher levels of certainty (Davila et al., 1997). These fluctuations may have been responsible for the modest correlations observed between the ESM attachment insecurity ratings and the preoccupied and dismissive attachment ratings on the RQ, which shows to be highly associated with fearful attachment ratings on the RQ.

Our results also indicate that some people may fluctuate more than others in their attachment representations. We observed that the clinical group not only reported higher levels of higher attachment insecurity, but also a higher degree of attachment fluctuations than the control group, suggesting that these individuals, who have a psychosis-spectrum diagnosis may have incoherent internal working models. Davila and colleagues (1997) propose that attachment instability may develop as a result of dysfunctional early care-giving environments that disrupt the development of coherent self and other models and manifest in unstable adulthood attachment. It has consistently been reported that psychosis is associated with a wide range of early adverse experiences (Varese et al., 2012). Some of these experiences of parental separation (Agid et al., 1999) neglect (Bentall, Wickham, Shevlin, & Varese, 2012; Sitko, Bentall, Shevlin, O'Sullivan, & Sellwood, 2014) victimisation through means

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of sexual abuse (Read, van Os, Morrison, & Ross, 2005), and of being unwanted at birth (Myhrman, Rantakallio, Isohanni, Jones, & Partanen, 1996) may result in disruptions to the development of early secure attachment relationships, and may subsequently lead to the development of incoherent self/others beliefs that fluctuate over time.

Although a number of studies have suggested that insecure attachment can increase vulnerability to developing psychosis (Read & Gumley, 2008), there is a paucity of research exploring the extent to which attachment insecurities are associated with the onset of psychotic symptoms in the flow of daily life. Our findings revealed that the occurrence of paranoid thoughts was preceded by elevated attachment insecurity, suggesting that, in everyday life, attachment representations may be responsible for maintaining paranoid experiences. It has been proposed however, that low self-esteem is common in individuals with paranoia (Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001; Garety & Freeman, 1999), and it could therefore be argued that self-esteem may also be a maintaining factor in paranoia, especially since experience sampling studies have demonstrated that low self-esteem precedes the occurrence of paranoid thinking (Thewissen et al., 2008; Thewissen et al., 2011). Our findings revealed that when self-esteem was controlled for, attachment insecurity continued to precede paranoid thinking, suggesting that attachment representations may play a more important role in understanding paranoid experiences.

Our findings further indicate the specificity of this effect by demonstrating that there was no relationship between attachment insecurity and auditory

hallucinations once paranoia had been controlled for. This kind of specificity is important as it points to the psychological mechanisms that are involved in

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experiencing specific symptoms. In a separate ESM study, for example, the experience of auditory hallucinations was shown to be specifically associated with dissociative experiences, and elevated levels of dissociation led to a subsequent increase in hallucinatory experiences but not paranoid thinking (Varese et al., 2011). Mapping these pathways may be extremely useful in clinical practice where

appropriate psychological mechanisms can be targeted during therapeutic interventions.

The findings should be interpreted in the context of several limitations. First, some participants used paper methods of data collection whereas others used an electronic method. Although it might be thought that the traditional paper diary method would be associated with poor compliance, it has been demonstrated that compliance rates are similar for both paper diary methods and electronic diary methods (Green et al., 2006). Second, the sample size might be criticized as being relatively small (20 per group), and further larger studies are needed to confirm our findings. Third, an affective pathway to psychosis has previously been proposed (ex. Myin-Germeys & van Os, 2007), and future studies should control for the effect of depression on paranoia. Fourth, although our findings show that attachment

appraisals do not affect frequency of auditory hallucinations, it has recently been proposed that there may be a link between attachment representations and appraisals of auditory hallucinations (Berry & Bucci, 2016). Fifth, although it has been

proposed that different affect regulation strategies may be employed by individuals with differing attachment styles, we are not able to examine each attachment style in an ESM framework. However, it is important to note that our ESM measure was validated against the RQ, and showed to be highly associated with the fearful (disorganised) ratings on the RQ. Finally, although the ESM method is longitudinal,

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it is important to be cautious about making inferences of causality from the data; it is possible that elevated levels of paranoia may also trigger changes in attachment representations, and this needs to be explored in future research.

To our knowledge, this is the first study exploring the temporal relationship between momentary attachment insecurity and symptoms of psychosis. There are several important clinical and theoretical implications. The findings demonstrate that attachment can fluctuate over very short periods of time, and that fluctuations in attachment representations appear to be more pronounced in individuals with

psychosis compared to healthy controls. Therefore, to obtain a greater understanding of one’s attachment representations, in addition to assessing attachment security, it may be informative to assess the level of attachment stability. Since experience sampling can be quite a laborious process for participants, the development of a quicker and easier to administer measure of attachment fluctuations may be

preferable for clinical purposes. The findings suggest that secure attachment may be associated with a lower risk of paranoia. This observation has the implication that, in therapeutic work, therapists should focus their interventions on addressing

attachment beliefs, and work towards establishing a sense of attachment security. Finally, in concert with previous epidemiological and cross-sectional studies that show an association between attachment insecurity and paranoia (Pickering et al., 2008; Wickham et al., 2015) the present findings suggest that policies that promote optimal relationships with caregivers in childhood may help to promote population mental health.

103 Acknowledgement

We would like to acknowledge the contribution of Amy Hammond, an undergraduate student, who helped with data collection of the control sample.

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108 Chapter 4

Dissociation moderates the association between attachment and paranoia.5

5 _{This paper has been submitted for publication as Sitko, K., Sellwood, W., &} Bentall, R. P. (in submission). Dissociation moderates the association between attachment and paranoia. Psychosis.

109 4.1 Abstract

Considerable evidence has shown that specific psychotic symptoms may be associated with specific psychological mechanisms. Insecure attachment has been proposed to be associated with paranoia, while dissociation has been suggested to be associated with hallucinations. As it is the norm for individuals with psychosis to experience multiple symptoms, this study addresses how these mechanisms interact in their effect on paranoia. 80 individuals with psychosis-spectrum diagnoses were recruited from inpatient and community teams. The findings revealed that the anxious and avoidant attachment dimensions, and dissociation were specifically associated with paranoia, and that dissociation moderated the effect of the anxious attachment dimension but not the avoidant attachment dimension on paranoia. These findings suggests that examining dissociation in individuals who experience paranoia may be informative, and that examining how psychological processes interact in their effect on symptoms may be important in understanding individuals who experience multiple psychotic symptoms. Finally this study shows that within the context of relationships, dissociation may be a response to events which threaten the self, suggesting that when working therapeutically, therapists should be aware that the dissociative process may be part of the defence mechanism protecting negative appraisals of the self.

110 4.2 Introduction

In recent years, considerable evidence has emerged that childhood trauma is a major risk factor for psychosis in adulthood, with consistent findings across multiple research designs and a dose-response relationship between severity of trauma and risk (Varese et al., 2012). Some studies (Bentall, Wickham, Shevlin, & Varese, 2012; Sitko, Bentall, Shevlin, O׳Sullivan, & Sellwood, 2014) but not all (van Nierop et al., 2014) have reported some specificity in the associations between types of childhood adversity and symptoms, with parental neglect and being raised in institutional care most toxic for paranoid symptoms and childhood sexual abuse most toxic for hallucinations. These observations have led some researchers to focus on two specific psychological mechanisms that may be related to these risk factors: dissociation and insecure attachment. A complication, which we address in this study, is that these processes may interact.